Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Friday, November 30, 2012

We will be speaking next Thursday, December 6th, at the New York Public Library and we'd love to meet you! We're under a program called The Thought Gallery, which sounds good for a psychiatric thing, right?

Details are HERE. The time is 6:30 pm to 8:30 pm.The Mid-Manhattan Library is located on the southeast corner of 5th
Avenue and 40th Street. It is diagonally across the street from the
Research Library (the Library with the lions). We will be on the 6th floor.

Thursday, November 29, 2012

I need a new obsession. It may be a few weeks, I still don't know how this new coding works, or what I'm going to tell my patients, or how I'm going to change my invoice system to deal with all the new codes. Over on KevinMD, I outlined all of my angst, plus my frustration with how the new coding deals with Medicare. Please do check out my Rant of the Day.

Tuesday, November 27, 2012

Over on Pete Earley's blog, he's posted a letter from desperate parents who can't get help for their son.Pete, as you may know, is a former Washington Post reporter, author of many books, and a mental health advocate. Yesterday, Pete answered the letter with 10 suggestions. He solicited a panel to take turns responding, and today, I'm the one with suggestions. Here's the letter, then do surf over to Pete's blog and check out the responses, more will be coming all week.

Dear Pete,We have tried to get our son professional help. I think he has
bipolar disorder, although he possibly could have schizophrenia. We know
he has an alcohol addiction. He has not cooperated with hardly
anything, and we’ve been unable to get him to go to our local mental
health center, although officials there said he is eligible for
treatment.We feel like our hands our tied. The few times that we’ve gotten
him to a psychiatrist, our son denies that he is sick, won’t take his
medicine, and is extremely hostile to doctors for the short time he’s
being seen by them. We’ve had him in our house for several months with
his erratic moods and high level of anger. Yesterday he asked to go to a
homeless shelter and he is now on the streets. If we try to visit him,
he runs away.His dad and I are at the point where we feel resigned that there
is no hope nor help for our son. The system has worked against us at
every turn … and he needs help. People have recommended “he needs to hit
rock bottom” and that we need to wait for him to *want* help. We simply
don’t know what to do. Do we wait for him to hit rock bottom on the
streets where we know he is not safe?In our view, the mental health network has been ineffective at
best, and is rolling the dice with people’s lives. Now we can see how
barriers in the mental illness system keep people from receiving basic
services. This has been hell for his dad and me, and I’m sure worse for
our son.If you have any advice please let us know.-A concerned parent.

The
blogger -Psych Practice- who posted on how to figure out an E/M code which I stole
below, did a wonderful job of giving a clear set of directions on how to do this,
though I have to say that I got nauseous half-way through because it is
so long and complex with so many charts, but it does explain it.

S/he wrote a follow-up blog post on how to code for a psychoanalytic
session with Socrates as an example (I was a little confused about the
Speech: Greek, Appearance: Toga, but I then I got it). Anyway, it's
very clever, and it makes the process seem a little less intimidating,
and it does a wonderful job of incorporating the E/M portion of the session into what naturally flows without requiring the therapist to collect irrelevant data for the sake of documentation. I hope it's right. So here's the link to the how to code E/M + add on therapy for the psychoanalysis of Socrates: http://psychpracticemd.blogspot.com/2012/11/em-psychoanalysis-note-monday.html

What this writer doesn't seem to take into account is the proclamation by AMA that the time spent on E/M must be completely distinct from the time spent on psychotherapy. Any one who has ever conducted or had psychotherapy knows, this is not possible. It's like the AMA decided the sky is now purple with orange polka dots. People come in and talk about what's important to them, and if they are depressed and have questions about that Abilify stuff they saw on TV, or are undergoing cancer treatments, or are about to have their knees replaced, that's what they talk about and it's not possible to define one part of a session as "psychotherapy" and instruct them to limit concerns about illnesses & treatments to a specific, time-distinct, portion of the session that is not "psychotherapy." I believe that we have to say that regardless of what Insurers, the AMA, or the APA believe, that it's simply not possible to disentangle the time devoted to the two. The stickiness of the issue is whether insurers/medicare are going to claim that if you have a 53 minute session and document a 99213 E/M code with a 90838 (60 minute psychotherapy add on) that you can't have done that much work seeing patients every hour and are going to insist that the therapy code be for the 45 (38-52 actually) minute shorter, session. For medicare, there is a $45 dollar pay increase if the psychotherapy session goes from 52 minutes to 53 minutes. I'm not the only one who thinks this is all nuts, right?

I am going to attempt to Live Tweet the 12/4 MPS CPT seminar with the hashtag #cpt. There's no WiFi at the Sheppard Pratt conference center, so I will be doing it from my phone's touchscreen, typos and all, to the extent that my stamina holds out. I practiced yesterday by tweeting Vani Rao's Grand Rounds at Hopkins on Traumatic Brain Injury (no, I didn't tweet the patient presentation). I know, I'm repeating myself, but I copied this from a email I put up on the psychiatric society's listserv.

Monday, November 26, 2012

Today, I live tweeted psychiatry Grand Rounds from Johns Hopkins on Traumatic Brain Injury. I've tried to do this before, but I got paged out after just a few tweets. Today, I made it through the whole lecture. I didn't tweet the patient presentation, just the lecture part. I didn't have my laptop, or WiFi access, so I did it from my iPhone on the touch screen where my fat fingers sometimes hit the wrong key. And while the speaker was excellent, she spoke really, really fast, and I missed a bit. I did my best. You can check it out at #jhhgr. My tweets are a bit disorganized and fragmented, but it's not really the venue for precision.Next week, the Maryland Psychiatric Society will be holding a seminar on how to do the new CPT coding and I'm hoping I can live tweet that. Again, no WiFi, and it will be my fingers flying as fast as they can on my phone. The seminar is much longer than the talk I tweeted today. Maybe the speaker will talk a little slower. So tune in, and if I can, I'll be tweeting the seminar at 6 PM on 12/4 using hashtag #cpt.

Sunday, November 25, 2012

With permission, I am stealing this entire post from Psych Practice, a NYC psychiatrist who was kind enough to go through a step-by-step How To Guide for determining and documenting the Evaluation and Management coding for the new CPT codes we'll be using in January. And thank you to Becca who found this for me. Now if someone could translate it into exactly what one needs to do when using these E/M codes in combination with the psychotherapy codes, that would be wonderful.

E;M Coding, in All Its Glory
There are three key components to E&M level of care: history, exam, and medical
decision making. Each of these components has requirements for meeting the
various levels of care. You need 2 out of 3 of these components to reach a specified
level of care. For example, if you have an extended problem focussed history, but
only 2 exam elements, you can still meet criteria for a 99213 provided your medical
decision making is of low complexity. It sounds confusing, but it’ll become clearer
as we move along. The details for each of these components follow, after which I’ll
give some examples.

Table 1

Level Of Care Requirements (2 out of 3 needed)

Level of Care

Hx

Exam

MDM

99212

Problem Focussed

1-5

Straightforward

99213

Extended Problem
Focussed

>6

Low Complexity

99214

Detailed

12 from 2 or more
organ systems

Moderate
Complexity

99215

Comprehensive

2 from each of 9
organ systems

High Complexity

Let’s look at each of the three components.
1. History:
History is broken into 4 parts, namely, CC, HPI (or Interval History for an
established patient), ROS, and PFSH (past medical, family, and social history).
CCis the presenting complaint for that session, and can be related to the diagnosis. Examples:“Anxiety”, or “F/U for Anxiety”

In case you were wondering, a CC is required for all notes, not just the initial
evaluation.
HPI or Interval Historyis comprised of the following elements:
• Location • Quality• Severity • Duration • Timing
• Context• Modifying Factors• Associated Signs and Symptoms
HPI is considered “Brief” if it includes 1-3 of these elements, and “Extended” if
it includes > 4 elements or 3 stable conditions.
Example:The patient c/o worsening anxiety x 1 week with panic symptoms that occur
intermittently, on average once per day, last for 5 minutes, and are brought on unexpectedly by
unclear precipitants.This would qualify as an extended interval history because it includes 4 elements:
severity, duration, timing, and context (or 5 if you include modifying factors).
ROSincludes pertinent positives and negatives. There are fourteen individual
systems recognized by the E/M guidelines:
• Constitutional (e.g., fever, weight loss) • Eyes• Ears, Nose, Mouth, Throat• Cardiovascular
• Respiratory• Gastrointestinal• Genitourinary• Musculoskeletal• Integumentary (skin and/or breast)

• Neurological• Psychiatric• Endocrine• Hematologic/Lymphatic • Allergic/Immunologic
Even in Psychiatry, it is possible to review more than one organ system.
Example:ROS positive for GI upset, SOB, diaphoresis, and dissociative feelings.
This example could arguably include GI, Respiratory, and Psychiatric. However,
it’s unclear what the liability is if you’re calling SOB respiratory, and then not
listening to the patient’s lungs.
PFSH-Pertinent Past Medical, Family, Social History

Past Medical History: a review of past illnesses, operations or injuries, which may
include:

Prior illnesses or injuries

Prior operations

Prior hospitalizations

Current medications

Allergies

Age appropriate immunization status

Age appropriate feeding/dietary status

Family History (FH): a review of medical events in the patient’s family which
may include information about:

The health status or cause of death of parents, siblings and children

Specific diseases related to problems identified in the Chief Compliant, HPI, or ROS

Diseases of family members which may be hereditary or place the patient at risk

Social History (SH): An age appropriate review of the patient’s past and current
activities which may include significant information about:

Marital status and/or living arrangements

Current employment

Occupational history

Use of drugs, alcohol or tobacco

Level of education

Sexual history

Other relevant social factors

Example:Patient is a graduate student in Physics, about to defend his dissertation.
Note: You DO NOT need to re-record a PFSH if there is an earlier version
available on the chart. It is acceptable to review the old PFSH and note any
changes. In order to use this shortcut, you must note the date and location of the
previous PFSH and comment on any changes in the information since the original
PFSH was recorded. For example, if you are seeing an established patient in the
office you can write: “Comprehensive PFSH which was performed during a
previous encounter was re-examined and reviewed with the patient. There is
nothing new to add today. For details, please refer to my previous note in this
chart, dated 11/23/2004.” (From EMUniversity.com)

Table 2

Levels Of History (3 out of 3 needed)

Level of Hx

HPI

ROS

PFSH

Problem
Focussed

Brief

None

None

Extended Problem
Focussed

Brief

1 System

None

Detailed

Extended

2 Systems

1

An example to clarify:In order to be able to bill for an E/M 99213 code, you need
to refer to Table 1, above, where you note that the required history is an extended
problem focussed history. In order to determine what constitutes an extended problem focussed history, you refer to Table 2, where you note that a brief HPI and 1 ROS are
enough to qualify.

• Fund of Knowledge-excellent• Affect-anxious• General Appearance-messy hair, not wearing socks, otherwise well-groomed.
This example includes 6 Psychiatric exam elements, and would therefore qualify as a 99213 level
of care exam.
3. Medical Decision Making- EMUniversity MDMThis part is a little tricky. You can check out the link, but I’ll try to summarize.
It seems as though you can raise the E/M code depending on the complexity of
your decision-making. But how the complexity is determined is, well, complex.
Referring back to Table 1, you’ll note that there are 4 levels of MDM:

Straightforward

Low Complexity

Moderate Complexity

High Complexity

Each of these, in turn, is broken down into 3 parts:

Problem Points

Data Points

Risk

So get ready for more tables.

Table 4, Levels of MDM
(2 out of 3 needed)

Overall MDM

Problem Points

Data Points

Risk

Straightforward

1

1

Minimal

Low Complexity

2

2

Low

Moderate Complexity

3

3

Moderate

High Complexity

4

4

High

Let’s look at how each of these parts is determined.

Table 5
Problem Points

Problem

Points

Self Limited or Minor (max of 2), e.g. common cold

1

Established Problem, Stable or Improving

1

Established Problem, Worsening

2

New Problem, no additional w/u planned, (max of 1)

3

New Problem, additional w/u planned

4

Example: “Patient with h/o anxiety, worsening over the last week,” would generate 2 problem
points.

Now let’s look at a complete note, and determine which E/M level it qualifies for:

Einstein, Albert DOB: 03.14.1879 Date of Visit: 11 11 12

Start:1:45p Stop:2:30p Total face to face time: 45 min

CPT: 90836, E/M ?????

CC:F/U for Anxiety

Interval Hx: The
patient c/o worsening anxiety x 1 week with panic symptoms that occur
intermittently, on average once per day, last for 5 minutes, and are
brought on unexpectedly by unclear precipitants, in the context of his
upcoming dissertation defense.

Psychotherapy Note: Discussed
with patient his automatic thoughts, and the specific concerns he has
about his dissertation defense. Reviewed relaxation techniques with
patient.

Plan:

Continue current medication

f/u 1/week psychotherapy

First, the History:
The Interval History includes at least 4 elements-severity, duration, timing, and
context. This makes it extended.
The ROS includes 3 systems, GI, respiratory, and psychiatric.
The PFSH includes one element of Social History, namely, that the patient is
a graduate student in Physics. Listing the allergies as NKDA may also qualify as
one element of PFSH.

Referring back to Table 2, History:

Level of Hx

HPI

ROS

PFSH

Problem
Focussed

Brief

None

None

Extended Problem
Focussed

Brief

1 System

None

Detailed

Extended

2 Systems

1

Extended HPI, 2 ROS, and 1 PFSH qualify as a detailed history.
Now the Psychiatric Exam:. 6 elements are noted, speech, thought, judgement,
fund of knowledge, affect, and general appearance. And the MDM:
Anxiety is an existing problem for the patient. Since it is worsening, this earns 2
problem points.
Referring to Table 6, it is clear that there are no data points.
And finally, risk. A chronic illness with mild exacerbation is considered moderate
risk.
Referring to Table 4, levels of MDM:

Overall MDM

Problem Points

Data Points

Risk

Straightforward

1

1

Minimal

Low Complexity

2

2

Low

Moderate Complexity

3

3

Moderate

High Complexity

4

4

High

In this case, the overall MDM would be of Low Complexity, since 2 out of 3 elements are needed.

To sum it all up, we look at Table 1, Levels of Care:

Level of Care

Hx

Exam

MDM

99212

Problem Focussed

1-5

Straightforward

99213

Extended Problem
Focussed

>6

Low Complexity

99214

Detailed

12 from 2 or more
organ systems

Moderate
Complexity

99215

Comprehensive

2 from each of 9
organ systems

High Complexity

Since there is a detailed history, but only 6 exam elements and MDM of low
complexity, this visit would qualify for a 99213 E/M code.

Now, if the patient also carried a diagnosis of depression, and this was stable, this
would earn a total of 3 problem points, 2 for the worsening anxiety, and 1 for the
stable depression. And 3 problem points would move the MDM up to moderate
complexity. And since only 2 out of the 3 key components are required for level of
care, a detailed history and MDM of moderate complexity would qualify as a
99214, which is reimbursed at a higher rate.

Overall, this is a pretty complicated business. It adds extra work to note-writing,
and it’s not really suited to Psychiatry, and certainly not to high frequency
psychotherapy or psychoanalysis. And I suspect that since this is completely new,
and doesn’t fit neatly into nice little well-established, categorized boxes, insurance
companies will also be confused about it. Or the’ll say they are so they can
withhold payment.